Member Grievance Form Member Name: Last First Middle Initial Member Address: Phone: City: State: Zip Code: Member ID#: Birthdate: Sex: Primary Care Provider Name: Complaint Where did the problem happen? (Name of hospital, doctor office or other location) When did this happen? (Include date) Who was involved? Please describe what happened: (Attach additional pages, if necessary) Have you made an attempt to resolve this problem? Yes No If you answered yes, please explain: What would you like to see done about this problem? Will you require language assistance? Yes No Language:
Member Grievance Form Do you have any physical or other limitations that would prevent you from attending a grievance meeting? Yes No If you answered yes, please explain:. I know and understand that Health Plan of San Joaquin will resolve my grievance within 30 days. I know and understand that my assistance is voluntary. However, failure to do so could affect my grievance. I know and understand that I have a right to: Appear before HPSJ s Member Grievance Committee; Disenrollment; Contact the Department of Managed Health Care (DMHC); File a State Fair Hearing (Medi Cal members only). Signature Date I approve Health Plan of San Joaquin to get the following in order to resolve a grievance on my behalf: Medical records; Claims records; Other data needed to resolve my grievance. Signature Date Did someone help you complete this form? Yes No if you answered Yes : Name: Relationship: Address: Telephone: Signature: Date:
YOUR RIGHTS UNDER MEDI-CAL MANAGED CARE If you still do not agree with this decision, you can: Ask for an Independent Medical Review (IMR) and an outside reviewer that is not related to the health plan will review your case Ask for a State Hearing and a judge will review your case You can ask for an IMR and State Hearing at the same time. You can also ask for one before the other to see if it will resolve your problem first. For example, if you ask for an IMR first, but do not agree with the decision, you can still ask for a State Hearing later. However, if you ask for a State Hearing first, but the hearing has already taken place, you cannot ask for an IMR. You will not have to pay for an IMR or State Hearing. INDEPENDENT MEDICAL REVIEW (IMR) The following paragraph will provide you with information on how to request an IMR. In this paragraph, the term grievance means the same thing as appeal. The California Department of Managed Health Care is responsible for regulating health care service plans. If you have a grievance against your health plan, you should first telephone your health plan at 209-942-6320 and use your health plan s grievance process before contacting the Department. Utilizing this grievance procedure does not prohibit any potential legal rights or remedies that may be available to you. If you need help with a grievance involving an emergency, a grievance that has not been satisfactorily resolved by your health plan, or a grievance that has remained unresolved for more than 30 days, you may call the Department for assistance. You may also be eligible for an Independent Medical Review(IMR). If you are eligible for an IMR, the IMR process will provide an impartial review of medical decisions made by a health plan related to the medical necessity of a proposed service or treatment, coverage decisions for treatments that are experimental or investigational in nature and payment disputes for emergency or urgent medical services. The Department also has a toll-free telephone number (1-888-HMO-2219) and a TDD line (1-877-688-9891) for the hearing and speech impaired. The Department s Internet Website (http://www.hmohelp.ca.gov) has complaint forms, IMR application forms, and instructions online. Prepared by the California Department of Health Care Services to help you understand your rights
STATE HEARING If you want a State Hearing, you must ask for one within 120 days from the date of this letter. However, if you are currently getting treatment and you want to continue to keep your treatment going, you must ask for a State Hearing within 10 days from the date this letter was postmarked or delivered to you, or before the date your health plan says services will be stopped or reduced. Please state that you want to keep getting your treatment going when you ask for the State Fair Hearing. You can ask for a State Hearing over the phone or in writing: If you decide to ask for a State Hearing by phone, please call 1-800-952-5253. This number can be very busy, so you may get a message to call back later. If you have trouble speaking or hearing, please call TTY/TDD 1-800-952-8349. If you decide to ask for a State Hearing in writing, you will need to fill out a State Hearing form or send a letter to: California Department of Social Services State Hearings Division P.O. Box 944243, Mail Station 9-17-37 Sacramento, CA 94244-2430 A State Hearing form is enclosed for you. Be sure to include your name, address, telephone number, Social Security Number, and the reason you want a State Hearing. If someone is helping you ask for a State Hearing, add their name, address, and telephone number to the form or letter. If you need an interpreter, tell us what language you speak, and we will provide one for free. After you ask for a State Hearing, it could take up to 90 days to decide your case and send you an answer. If you think waiting that long will harm your health, you might be able to get an answer within 72 hours. Ask your doctor or health plan to write a letter for you. The letter must explain in detail how waiting for up to 90 days for your case to be decided will seriously jeopardize your life, your health, or your ability to attain, maintain, or regain maximum function. Then, ask for an expedited hearing, and provide the letter with your request for a hearing. LEGAL HELP You may speak for yourself at the State Hearing or have another person speak for you, such as a relative, friend, advocate, doctor, or attorney. If you want another person to speak for you, then you must ask the other person yourself. You may be able to get free legal help. Call the Consumer Complaint and Protection Coordinators at 1-800-952-5210. You may also call the local Legal Aid Society in your county at 1-888-804-3536.
NONDISCRIMINATION STATEMENT Health Plan of San Joaquin complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Health Plan of San Joaquin does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. Health Plan of San Joaquin: Provides free aids and services to people with disabilities to communicate effectively with us, such as: - Qualified sign language interpreters - Written information in other formats (large print, audio, accessible electronic formats, other formats) Provides free language services to people whose primary language is not English, such as: - Qualified interpreters - Information written in other languages If you need these services, contact our Customer Service Department 888.936.PLAN (7526), (TTY/TDD) 711 HOW TO FILE A GRIEVANCE If you believe that Health Plan of San Joaquin has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Health Plan of San Joaquin Attn: Grievance Coordinator 7751 S. Manthey Rd. French Camp, CA 95231 You can also call our toll free number by calling 888.936.PLAN (7526), (TTY/TDD) 711, or fax it to 209.461.2550 Attn: Grievances. You can file a grievance in person or fill out our online form, fax, or email. If you need help filing a grievance, HPSJ s Grievance Department is available to help you. OFFICE OF CIVIL RIGHTS You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C. 20201 800.368.1019, 800.537.7697 (TDD) Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html. Questions? Call 888.936.PLAN(7526) TTY/TDD 711 www.hpsj.com CL06162017-R Notice of NondiscriminationEng
Get help in your language LANGUAGE ASSISTANCE SERVICES English ATTENTION: If you speak another language, free language assistance services are available to you. Call 1-888-936-(PLAN)7526 (TTY: 711). Español (Spanish) ATENCIÓN: Si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-888-936-(PLAN)7526 (TTY: 711). Tiếng Việt (Vietnamese) CHU Y : Neu bạn nói Tieng Việt, có các dịch vụ ho trợ ngôn ngữ mien phı dành cho bạn. Gọi so 1-888-936-(PLAN)7526 (TTY: 711). Tagalog (Tagalog Filipino) PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa 1-888-936- (PLAN)7526 (TTY: 711). 한국어 (Korean) 주의 : 한국어를사용하시는경우, 언어지원서비스를무료로이용하실수있습니다. 1-888-936-(PLAN)7526 (TTY: 711) 번으로전화해주십시오. 繁體中文 (Chinese) 注意 : 如果您使用繁體中文, 您可以免費獲得語言援助服務 請致電 [1-888-936-(PLAN)7526 (TTY: 711) Հայ երեն (Armenian) ՈՒՇԱԴՐՈՒԹՅ ՈՒՆ Եթե խո սո ւ մ եք հայ ե րեն, ապա ձե զ ան վ ճ ար կար ո ղ են տր ամադ րվե լ լե զ վ ակ ան աջ ակ ց ո ւ թյ ան ծառ այ ո ւ թյ ո ւ ն ն ե ր : Զան գ ահ ար ե ք 1-888-936-(PLAN)7526 (TTY (հե ռ ատի պ) 711): Русский (Russian) ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните 1-888-936-(PLAN)7526 (телетаи п: 711). Questions? Call 888.936.PLAN(7526) TDD/TTY: 711 www.hpsj.com 1 CL06232017-R LangAssistance_Tag_15
توجھ: اگر بھ زبان فارسی گفتگو می کنید تسھیلات زبانی بصورت رایگان برای شما فراھم می باشد. با( 711)-936-888-1 (TTY: PLAN)7526 تماس بگیرید. ( Farsi )فارسی 日本語 (Japanese) 注意事項 : 日本語を話される場合 無料の言語支援をご利用いただけます 1-888-936-(PLAN)7526 (TTY: 711) まで お電話にてご連絡ください Hmoob (Hmong) LUS CEEV: Yog tias koj hais lus Hmoob, cov kev pab txog lus, muaj kev pab dawb rau koj. Hu rau 1-888-936-(PLAN)7526 (TTY:711). ਪ ਜ ਬ (Punjabi) ਧਆਨ ਦਓ: ਜ ਤ ਸ ਪ ਜ ਬ ਬ ਲਦ ਹ, ਤ ਭ ਸ਼ ਵ ਚਸਹ ਇਤ ਸ ਵ ਤ ਹ ਡ ਲਈਮ ਫਤਉਪਲਬਧਹ 1-888-936-(PLAN)7526 (TTY: 711) 'ਤ ਕ ਲਕਰ ( Arabic )العربیة ملحوظة : إذا كنت تتحدث اذكر اللغة فا ن خدمات المساعدة اللغویة تتوافر لك بالمجان. اتصل 1-888-936-(PLAN)7526 رقم ھاتف الصم والبكم 711 برقم ह द (Hindi) ध य नद : यदआप ह द ब लत ह त आपक लएम फ तम भ ष सह यत स व ए उपलब ध ह 1-888-936-(PLAN)7526 (TTY: 711) परक लकर ภาษาไทย(Thai) เร ยน: ถ าค ณพ ดภาษาไทยค ณสามารถใช บร การช วยเหล อทางภาษาได ฟร โทร 1-888-936-(PLAN)7526 (TTY: 711). ខរ(Cambodian) របយ ត ប រ ស នអ កន យ ខ រ, បសជ ន យខនក យម នគ ត ឈល គ ចនស ររប រ អ ក ច រ ទ រស ព 1-888-936-(PLAN)7526 (TTY: 711) Questions? Call 888.936.PLAN(7526) TDD/TTY: 711 www.hpsj.com 2 CL06232017-R LangAssistance_Tag_15